Advanced Wiring Techniques for Complex femoropopliteal ...
Transcript of Advanced Wiring Techniques for Complex femoropopliteal ...
Advanced Wiring Techniques for Complex femoropopliteal
Obstructions
Hiroyoshi Yokoi, MD
Fukuoka Sanno Hospital
Fukuoka, Japan
Disclosure
Speaker name:
..................Hiroyoshi Yokoi...............................................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s) Cook, Termo, BSJ,BIRD
I do not have any potential conflict of interest
☒
Geographical Scope of EVT Physicians
North America
• 40% VS• 40% IC• 20% IR
Europe
• 30% IC• 50% IR• 20% VS
• 10% IC• 15% IR• 75% VS
• 10% IC• 70% IR• 20% VS
• 30% IC• 35% IR• 35% VS
Asia-Pacific
• 10% IC• 30% IR• 60% VS
• 80% IC• 5% IR• 15% VS
Latin America
• 20% IC• 30% IR• 50% VS
IC; Interventional Cardiologist IR; Interventional RadiologistVS; Vascular Surgeon
• 80% IC• 5% IR• 15% VS
Japanese EVT-CTO wiring techniques developed from PCI
Progress of CTO-EVT in Japan
Factors contributing to progress of CTO EVT
• Antegrade approach
0.014-0.018 stiff and taperd CTO wire technology
Imaging Guided approach (Surface echo, IVUS)
• Retrograde approach
Distal site puncture technique
Trans-collateral approach
Progress of CTO-EVT in Japan
Factors contributing to progress of CTO EVT
• Antegrade approach
0.014-0.018 stiff and taperd CTO wire technology
Imaging Guided approach (Surface echo, IVUS)
• Retrograde approach
Distal site puncture technique
Trans-collateral approach
Which wire is appropriate for CTO ?
0.014 or 0.018 or 0.035
In Japan, 0.014-0.018 inch guidewire is favorable than
0.035-inch guidewire in CTO intervention
BTK/SFA SFA/Iliac SFA/Iliac
How I shape the tip of guidewires?
How to handle guidewires for CTO lesions?
• There are 3 types of techniques to manipulate the guide wires :
1) Sliding Technique
2) Controlled Drilling Technique
3) Penetrating Technique
• For the micro-channels present ,1) may be better.
Tapered tip plastic-jacket hydrophilic GW
• For the usual or tortuous lesions, 2) may be better.
Non tapered tip GW or hydrophilic plastic GW
• For the very hard lesions, 3) may be better
Tapered tip GW with strong penetration power
How to handle guidewires for CTO lesions?
• There are 3 types of techniques to manipulate the guide wires :
1) Sliding Technique
2) Controlled Drilling Technique
3) Penetrating Technique
• For the micro-channels present ,1) may be better.
Tapered tip plastic-jacket hydrophilic GW
• For the usual or tortuous lesions, 2) may be better.
Non tapered tip GW or hydrophilic plastic GW
• For the very hard lesions, 3) may be better
Tapered tip GW with strong penetration power
First choice & main GW
Polymer-jacketed GW
・ Regalia XS 1.0・ Chevalier・ Command・ Jupiter FC
Standard GW for SFA&BTK intervention
Regalia XS 1.0 (Asahi Intecc)
Chevalier 14 Floppy
0.014inch
Radiopaque length 3cm
Polymer Jacket(Coil Inside)12cm
Total length:235cm
PTFE CoatingHydrophilic Coating
Tip weight: 2g
Strong point is “Trackability”Stainless steal shaft
Super strong durability
Hi-Torque Command (Abbot)
Coil length:8 cm
Hydrophilic coating length:55cm
0.014inch
Total length:235 cm
不透過長:3 cm
NiTi Core Shaft : 55cm SUS Core Shaft
Polymer coating length:39cm(invisible polymer)
Hybrid core system(Niti+SUS)Polymer Jacket
Hydrophilic coating
Differences in each PJ-GWs
・ Regalia XS 1.0Basic GW , Safe, Poor durability
・ Chevalier floppyControllable GW; Good Trackability & Pushability
・ HT-CommandStrong durability but slightly stiff (Tip weight; 3g)
・ Jupiter FC/ FC3Balanced (Trackability, pushability & Durability)
How to handle guidewires for CTO lesions?
• There are 3 types of techniques to manipulate the guide wires :
1) Sliding Technique
2) Controlled Drilling Technique
3) Penetrating Technique
• For the micro-channels present ,1) may be better.
Tapered tip plastic-jacket hydrophilic GW
• For the usual or tortuous lesions, 2) may be better.
Non tapered tip GW or hydrophilic plastic GW
• For the very hard lesions, 3) may be better
Tapered tip GW with strong penetration power
Treasure is a hydrophilic coated 0.014-0.018” PTA guidewire, which possesses superior torqueability due to its structure using thick stainless steel wires for the spring coil.
70mm 80mm 0.018 inch
150mm (Pt Coil)Hydrophilic Coating PTFE Coating
12g
High torque performance
Good for controlled drilling
From June 2004
Detailed characteristics
Composite Core
Micro-cone tip
Tip load 12gf
Balanced power to cross the highly resistant lesions
Mini pre-shape
Balanced support shaft
design
Torque response
Penetrability
Shape retention
Push transmission Easily catches the entry point
of the occluded lesion
Easy directional control
Advantages in the occluded lesion
How to handle guidewires for CTO lesions?
• There are 3 types of techniques to manipulate the guide wires :
1) Sliding Technique
2) Controlled Drilling Technique
3) Penetrating Technique
• For the micro-channels present ,1) may be better.
Tapered tip plastic-jacket hydrophilic GW
• For the usual or tortuous lesions, 2) may be better.
Non tapered tip GW or hydrophilic plastic GW
• For the very hard lesions, 3) may be better
Tapered tip GW with strong penetration power
Astato is a 0.014-0.018” hydrophilic coated PTA guidewire, which possesses high penetration power with its 30g tip load and tapered design down to 0.013”.
0.013inch0.013inch
30g150mm (Pt Coil)
Hydrophilic coating
High penetration force
Good for penetration
From August 2006
Radiopaque 3cm0.014inch
PTFE CoatingHydrophilic Coating
Length:190cm : SUS core
Tip load 45g,100g
25°1mm pre-shaped
Jupiter MAX product spec.
CTO Wire Escalation Techniques
Hybrid Sliding-Drilling-Penetration
Sliding (if micro-channel present)
(Polymer jacketed guidewire)
↓Not cross
Controlled Drilling
(Treasure XS 12, Halberd)
↓Not cross
Penetrating
(Astato XS 30,Jupiter 45,MAX)
↓Not cross
Retrograde Approach
Intraluminal vs. subintimal
All the effort we do for getting the intraluminal space
using several techniques and devices.
Rapid Exchange Lumen & OTW Lumen
Dual Lumen Catheter
Rapid Exchange Lumen(0.014inch)
OTW Lumen(0.014inch)
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AMC-K14095
Micro-cone tipTip load 7.5gf
Deflection and directional control with the balanced penetration force and torque response
Deflection control
Balanced support shaft
design
Composite Core Torque response
Penetration
Push transmission Easily catches the entry point
of the occluded lesion
Easy directional control
Advantages in the occluded lesion
Detailed characteristics
Mini pre-shape Shape retention
Progress of CTO-EVT in Japan
Factors contributing to progress of CTO EVT
• Antegrade approach
0.014-0.018 stiff and taperd CTO wire technology
Imaging guided approach (Surface echo, IVUS)
• Retrograde approach
Distal site puncture technique
Trans-collateral approach
Scenery of Cath-Laboduring Ultrasound Guided EVT
by courtesy of Miyamoto
Guidewire Crossing of CTOsunder Ultrasound Guidance
SFA Just CTO 0.014inch GW
by courtesy of Miyamoto
To identify in which direction the true
lumen is present.
IVUS-guided parallel wiring
CTO-exit
wire preceding
IVUS-guided technique for long SFA CTO
Prox
Mid
Dis
IVUS
preceding
wire preceding
wire preceding IVUS preceding
or
((((
(((( ((((
((((
IVUS preceding
SFA-proximal to mid
by courtesy of Kawasaki
Wire preceding
by courtesy of Kawasaki
Progress of CTO-EVT in Japan
Factors contributing to progress of CTO EVT
• Antegrade approach
0.014-0.018 stiff and taperd CTO wire technology
Imaging Guided approach (Surface echo, IVUS)
• Retrograde approach
Distal site puncture technique
Trans-collateral approach
Peroneal puncture Metatarsal puncture Plantar puncture
Take Home Message
• EVT for SFA- CTOs is still technically developing.
• Generally, we have to be very flexible to change
our strategy during EVT.
• We have to be familiar with all of the techniques,
which have been developed.
Advanced Wiring Techniques for Complex femoropopliteal
Obstructions
Hiroyoshi Yokoi, MD
Fukuoka Sanno Hospital
Fukuoka, Japan